Nick's FatPadTrim, Medial plica/Distal patella excision, AIR x2, LMR 3in1 Diary

[Puffy the Knee Slayer]

Hi Nick,

I am sorry you are now having problems with your hip as well, and that physio seem to be condemning you to managing your pain rather than resolving the problem.

I hope the MRI will provide useful information and show something that can be tackled.

You are right though we are used to getting setbacks, persevere and hopefully something else will emerge that can be done to help. It is a long road.

[Clarkey]

18/12/16 29 Months Day 883 Post Op

Here is my latest review from my consultation with the sports medicine doctor, finally my right knee problem treatment is coming to a final decision after all the conservative treatments have failed. I am really hoping that this time round my MRI comes back positive for a change after not being able to run for 4 years in January. Walking at a slow pace with a noticeable limp with crunching/cracking sounds recently! Surely there has to be an internal problem inside the kneecap.


Dear ****

I re-reviewed Nicholas in Clinic. Unfortunately the loading programme supervised by **** ***** Physiotherapist, and the shockwave treatment has not provided any improvement in symptoms. Nicholas found initially the loading did help but found that the loaded exercises aggravated his symptoms if anything.

Nicholas is now flagging some new symptoms around his knee. He is experiencing some clicking and general feeling of instability. He is known to have a fixed flexion contracture secondary to arthrofibrosis. He is also describing some right lateral hip pain which again is associated with clicking.

Clinically today he is not especially tender on palpation through the right patellar tendon but has some general discomfort on end of range of flexion. McMurray's is uncomfortable but does not produce a click. His right hip has a well-preserved internal rotation of 15 degrees but the FADIR position is sore. He is stiff and sore at end of range of FABER testing.

In light of these new symptoms I think it is worth performance an X-ray of pelvis to rule out hip dysplasia as well as an MRI of the right hip to rule out any labral pathology. I will also re-MRI scan the right knee to look for any occult pathology.

Nicholas did discuss whether he felt an upright MRI scan done privately would be helpful. I do not not think it would be. He also discussed with me whether re-referral to Professor Snow would be wise for a potential diagnostic arthroscopy. I have explained that I think these investigations are important and they should be done intially prior to a referral. I will see Nicholas again with the results of the imaging.

Many thanks

Yours sincerely,

*** *****

Consultant in MSK & Sports Medicine.


With my latest assessment showing up new knee symptom problems hopefully the MRI scan will pick it up easily this time round. I was going to have an interview as a Playworker for autistic kids in November after volunteering for the organisation for over 18 months. My right knee and hip is hindering my chances of employment. Felt useless when they went an indoor trampoline park as I could not join. Instead I spent time with a service user that cannot be close proximity to others. If a child needs the toilet two playworkers are required due to historical sexual abuse cases, I was useful after all but I do miss not taking part in physical activities.

It says on job description need to be physically fit and active to take part in sporting activities. I can help out with swimming as there minimal impact on the joints. The Manager is more concerned if a playworker cannot swim as it's an essential part of the job description. I have been complemented how well I interact and support service users during one to one sessions by the leaders I work under. They should consider my physical disabilities pairing me up with service users on wheelchairs and with MS etc. Classed as discrimination not taking me on due to my joint problems.

Puffy, Thanks for responding, we both know from our personal experiences the setbacks we have to face and often not are not taken seriously until it gets to a stage when the knee become so bad that they finally need to do something to ease the pain and discomfort.

Happy Christmas, hopefully 2017 will be the turning point of finally getting to our never ending knee sagas sorted out.

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[Clarkey]

09/01/17 29 Months Day 905 Post Op

Not the greatest start to 2017 that's largely down to my right knee and hip problems! I have been volunteering at the young people’s autism group for 2 years in April and have been doing one to one for the whole session. The Leader has no concerns about my mentoring skills and ready for employment as the organisation has increased funding in 2017. They can now take on more playworkers and service users at the various clubs throughout the Birmingham region.

My right knee and hip problems is a concern right now, ideally staff have to be physically fit or can become a safeguarding concern! An example if a service user ran off I could not give chase and the club do lots of sporting activities that I am physically unable to do as I cannot walk quickly or run. It is frustrating and stressful as I know I can do the job to a high standard, the club I help out at are looking to employ a new playworker and already known by staff and service users and someone autistic does not like new faces. They have known me well, it is my knee and hip problems that is stopping me getting a paid job.

I have qualifications in horticulture and could do a gardening job but it flares up my right knee and hip. I was offered a job during the growing season starting from March 2017 to maintain people’s garden by the Director of the autism charity shop. I had to turn down the job offer due to my on-going right knee/hip injury.

I have got a date for the MRI scan on Friday 27th January 2017 @15:50 for both my right knee and hip with the results on Tuesday 31st January when I see the Sports Medicine Doctor. Hopefully this time round the MRI scan comes back positive that show something concrete to try and fix or at least ease some of the pain and discomfort and increase my mobility so I can finally for fill my dream job.

Will remain positive and try not to let the setbacks mentally torment me by carrying on volunteering for adults and young people with additional needs at the various clubs I help out at. 

Happy New Year, hopefully 2017 us KneeGeeks can get out knee problems sorted out.

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[Puffy the Knee Slayer]

That sounds really frustrating that both your career options are being impeded by your knee, especially when you have worked so hard volunteering for so long and building relationships with the people who use the service and colleagues etc and you know the job would be the perfect fit for you were it not for your injury.

The only thing I can think of is asking for a reasonable adjustment under the Equality Act 2010 to accomodate your knee problem, but I am not sure on the legalities of it, if being able to run around after young people is an essential requirement of the post. You could maybe discuss it with them? But if being fit is part of safeguarding i am not sure.

Of course I know the best option would be for the knee problem to be resolved!

Will keep my fingers crossed for your MRI date (am still waiting for my date) and hope that whatever is causing the continuing problems shows up so they can go in and sort it out for you. Good luck.

[Clarkey]

18/01/17 30 Months Day 914 Post Op

The long wait will soon be over to get into the next phase of what seems to be a never ending right knee saga. Nine days until my MRI scan of my right knee and hip and x-ray of my hip and thirteen days for the results of the scans. It might come back negative again which would be frustrating. I am hoping this time round it comes back positive for a change. At least then Prof Snow has something he can work on straight away rather than risking doing a diagnostic arthroscopy.

It also makes sense to further investigate the right hip that could be contributing towards the anterior knee pain and discomfort. I do at times feeling my right hip popping when I am doing left leg wall squats. I would be very surprised and shocked if surgery was suggested as the pain at the moment is perfectly ok and manageable. Maybe if the kneecap is realigned it will ease some pressure away from the hip. The Registrar so far is the only person to pinpoint the anterior knee pain! He was spot and suggested doing an ‘osteotomy’ at 1st I thought his suggestion and orthopaedic knowledge was too invasive. Now it does not seem so crazy after all.

I would go through anything even if it was an invasive surgery to go through; if it was a success I could forget the bad times and move on with the good times hopefully? It might not even happen if the MRI scan comes back positive with a straight forward surgical fix.

Puffy, I agree with you that it could be going against the 'Equality Act 2010' to say my knee and hip problems could stop me from gaining employment. I have seen staff with mobility issues at the annual two day staff and volunteers training last year during the Summer Holiday period. I even chatted to one staff saying he knows staff with joint problems.

Thanks for the wishing me good luck, I am hoping this time round I am able to finally make some progress after being patience for such a long time period. It is now looking as if it is coming to a final decision.

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[Puffy the Knee Slayer]

If there are other staff there with joint problems it could indicate discrimination, though their roles may not be the same as yours.

Might be worth looking into, you could give ACAS a ring and ask for advice?

Have you got a job description for the paid post, does it say you must be able to run around after service users?

I know what you mean about wanting a surgical fix and being willing to go through anything to get to the point where you could move on from this injury, it has dragged on for so long.

Well i hope there will be a resolution for both our right knees soon. Good luck on the 27th.

[Clarkey]

30/01/17 30 Months Day 926 Post Op

My MRI scan of my right knee and hip went smoothly on Friday afternoon one can always rely on a friendly nurses at the Birmingham Royal Orthopaedic Hospital. My 1st scan was my right hip going head first right into the back of the tunnel! This is the first time that I have experienced going right to the end of the tunnel. It was not too bad having ear plugs plus headsets listening to a local radio station. I then had my right knee scanned and went feet first into the tunnel with head outside the tunnel that was less daunting. I think I have now had 5 MRI scans on my right knee and 1 on my hip making a total of 6. Only one out of five came back positive. I am looking at the results tomorrow once again coming back with nothing of a major concern.

What ever the results are when I find out tomorrow morning I will ask at this stage to take a risk and gamble and go for a diagnostic arthroscopy. Even my mum with her new left knee and hip is now able to go at the same pace as me. I was lagging behind at the autism young people's Saturday Club, enough is enough action needs to be taken now. Might not have to ask if for the 2nd time if my MRI scan comes back positive.

Fingers and toes crossed that the results show something that can be eased or fixed when I see the Sport Medicine Doctor tomorrow morning. I have been told to arrive earlier for the consultation to have a x-ray on my pelvis and not right hip that I now see was written in my report. This will rule out dysplasia of the hip. I am hoping that my right hip will not require surgery! This would be a big shock and surprise if it was considered.

Puffy, I will see what the outcome and treatment plans are set in place after my consultation before worrying about not being employable. We have both got to a stage where patience is wearing thin and just want it sorted out even if it drastic measures it is a risk worth taking.

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[Clarkey]

31/01/17 30 Months Day 927 Post Op

As I predicted the Sports Medicine Doctor had a quick look through both MRI scans and said that in comparison to my last MRI scan in December 2015 that the two scans look very similar with no significant changes. However Prof Snow has not yet reviewed my latest MRI scan, he should be able to pick up any potential new problems. There will be a team meeting with other OS’s to look at my hip MRI scan to decide what course of treatment would be beneficial on Friday.

The right hip MRI scan showed fluid that may require an x-ray guided injection, my mum said she found her hip injection last year extremely painful! I should ask for numbing or semi sedation before having the injection. This may resolve the knee pain but it could also be the opposite way round.

The Sports Medicine Doctor is more concerned with the hip pain and discomfort that I feel more when I have driven for a certain amount of time. The pain is moderate nudging pain and discomfort around the hip bone, buttocks and groin area. I am pre-booked for the injection that I expect will be an OS that deals with young adult hip pain. If you are under 60 in medical terms you are classed as a young adult. Another 22 years before I am classed as elderly.

I am going to stick to what I have said all along despite being pre-warned by the Sport Medicine Doctor and 2nd opinion from OS in June 2016, I am happy and willing to risk and gamble by going for a 3rd diagnostic arthroscopy. When I give my consent signing my signature. If it makes my knee worse then I am to blame and not Prof Snow by taking on full responsibility for my actions.

It has been dragging out for far too long now and entitled to go ahead with a diagnostic arthroscopy, I am not a big fan of MRI scans as they are never 100% reliable. Scar tissue and fluid in the knee could be clouding the MRI scan. Pre-op to scope #1 and #2 I was not limping around like an old man and the pain and discomfort was manageable. I had the surgery in the hope that I am would be able to return to long distance running.

My career path is being put on hold due to my right knee problems, I will admit defeat after a 3rd diagnostic arthroscopy. I can then feel reassured that I have tried out every treatment option available. I have previous reports from Prof Snow saying he is happy to do surgery if ESWT and PT failed. The Sports Medicine Doctor told my mum Prof Snow has not yet had a chance to review the MRI scan so cannot really advise me at this point. His concerns are that I might be worse off if I had surgery as I scar up excessively.

It might sound as if I am crazy to risk it all, it not pride that is making me decide to go ahead with a risk and gamble of surgical intervention. I know my right knee is a major hindrance not just physically, also mentally. I am fed up not making any progress by going around in circles.

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[Aly0108]

Nick,

After your story, I will never to do surgery for my hoffa's.  Now my left knee hurts a lot, maybe because it is winter, but I have a sharp pain. I dont want to return at PT, because their exercises aren't for my fat pad problem. I do isometric exercises to build my VMO.  I think, we have to fix maltracking knee caps, because  knee caps irritate fat pad, but  that is no easy.
Read this post. I speak with him, and now he doest have problem with knees et fat pad, he fixes with surgery TTT.
http://www.kneeguru.co.uk/KNEEtalk/index.php?action=profile;area=showposts;u=34887
 
I suggest you, no more surgery. Try to fix your knee caps. I know, when knee is painful, quad muscle stop worked.

[Puffy the Knee Slayer]

Nick,

After your story, I will never to do surgery for my hoffa's.  Now my left knee hurts a lot, maybe because it is winter, but I have a sharp pain. I dont want to return at PT, because their exercises aren't for my fat pad problem. I do isometric exercises to build my VMO.  I think, we have to fix maltracking knee caps, because  knee caps irritate fat pad, but  that is no easy.
Read this post. I speak with him, and now he doest have problem with knees et fat pad, he fixes with surgery TTT.
http://www.kneeguru.co.uk/KNEEtalk/index.php?action=profile;area=showposts;u=34887
 
I suggest you, no more surgery. Try to fix your knee caps. I know, when knee is painful, quad muscle stop worked.

Hi Aly,

TTT is quite drastic surgery for fat pad and maltracking problems, have you had a Dysport injection into the TFL suggested to you? You then do physio to build up medial quads while lateral quads are temporarily switched off. Tracking should improve and reduce fat pad inflammation. It has helped me to an extent (though am now having lateral pain!)


@Clarkey - can understand you are willing to risk it all but please be careful you do not want to end up in an even worse position than you are now. If the best outcome is that there is no change I would go for it but if there is a risk you could be even worse I would not do it, though it's up to you as only you know how badly your knee is affecting you.

[Vickster]

Agreed.  Nick, do NOT rush into more surgery on the knee unless you are sure that you will benefit from it.  You could find that the hip is a cause of some/all of the issues, make sure that is fully investigated and that you manage it conservatively before doing anything surgical.  It's slow, frustrating, but messing further with the knee could mess with the hip and vice versa.  These things are often linked (my knee issues are now causing me foot issues so I'm having to manage both)

I don't know if Prof Snow does hips as well as knees, if not, and a Consultant appointment is needed, find an OS who does both joints and understands how to treat both in harmony.  Otherwise, the sports doc sounds very sensible and on the ball (and won't be knife happy)

Good luck

[Clarkey]

Hi All,

Thanks for the links and concerns towards having a 3rd diagnostic arthroscopy, despite your pre-warnings and the Sports Medicine Doctor caution towards surgery I need to go ahead as I am convinced that for soft tissue injuries of the knee MRI scans serve no purpose. I could have extensive damage to the cartilage that MRI can often not pick up on! It is a lot more stressful for me personally to put an ending to trying to find a way to ease the pain and discomfort in my right knee.

Never knowing what could be wrong inside the knee would drive me insane! I said before I will feel more relaxed and at ease knowing I have tried every available option one cannot put 100% trust on an MRI scan. I still feel that the Registrar I saw was spot on that I am a borderline case for knee realignment surgery after having the CT scan results that is a major surgery but could work out well in the long run. He is the only one so far who managed to pinpoint the pain in the exact location I am feeling at the bottom of my kneecap and tibia. Prof Snow, 2nd OS and Sports Med Doc all could not pinpoint the pain like the Register managed to do.   

Aly, link about TTT surgery is similar to an Osteotomy I can feel the weight going into my foot and ankle if I try to speed up my walking pace. Changing the angle of the knee could make a big difference to my never ending right knee problems.

We might be having this discussion for nothing as Prof Snow has not had a look at the MRI images who is the knee expert while the Sports Med Doc has less knowledge to spot new problems on the MRI who had a quick flick through the images. On my 1st scan it mentioned that my patella was on the low end of normal. 

I respect your concerns and worries and thank you for advising me. I am happy to risk it at this point and can blame myself only if it all goes pear shaped! Or could be posting saying I was right to take a risk with a success story.

It would come across better if I tell the autism kids manager that my consultant will do a diagnostic arthroscopy to see if there any damage to the knee or can say goodbye to my dream job as a care support playworker for autistic kids.   

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[Clarkey]

A success story from crankerchick who almost gave up hope with her ongoing knee problem.

I'm a little late in posting this, as ironically, I was in Houston attending a technical conference on my kneeniversary.

Yes, 7 years since I had my left leg corrected for the mal-alignments that caused me so many problems for so many years. I couldn't be more grateful for the resources, help, and support I received here to get to the root of the problems and save me from the surgical mistake that was to be a Fulkerson TTT and lateral release in the presence of femoral anteversion and excess tibial torsion.

At 7 years out, I am 100% free of the pain and instability I dealt with for so many years. I walk, run, jump, kick, bowl, bike, and generally do anything I want to do without knee pain or instability. I'm the mother of a fabulous 2-year old that I'm able to care for confidently, without worrying of falling down as I run behind her.

I'm 90% free of the collateral damage of surgery to my femur and tibia. I do have tenderness internally   on the soft tissue of the femur that only bothers me when I lay on hard surfaces on that side. It's interesting, though, that even at 7 years out, this does still fade with time. I noticed a few months ago I was laying on the floor on that side in my daughter's room playing with blocks and I was laying on that side and didn't even feel it. The tibia is 99% pain free. It's a little odd sensation along the incision, and definitely still numbness lateral to the incision, but it's not painful at all and probably will never go away completely.

So my update is this. If you still read this, or if you come across it in your research. Do yourself a favor and make sure you have yourself thoroughly evaluated by a doctor that will look at each leg individually and will evaluate you for bony mal-alignments including knock-knees, bowed-legs, and excessively rotated femurs and tibias. This is not something that can be thoroughly evaluated by looking at your legs or regular x-rays. They are best quantified with rotational ct-scans and standing leg length x-rays. I found my doctor, Dr. Mark Sanders, in Houston, TX at the Sanders Clinic. There are choices out there and not every doctor is aware of or willing to evaluate these problems but is all too willing to do a cookie cutter procedure due to the presence of instability. It's important to treat the problem, not the symptom. I was able to eventually find a doctor that diagnosed the problem rather then just propose a surgical fix for the symptoms. I won't trust my legs to any other doctor now.

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[Puffy the Knee Slayer]

Sorry Nick I am  not clear, are you saying you are going ahead with osteotomy or you are wanting to have a diagnostic arthroscopy?

I'm happy it worked out for crankerchick, I don't want to be negative and everyone's situation is different, I was told for me the TTT had only a 50% chance of success so I did not think it was worth the risk, for me. I wouldn't have the dosh to go to Houston anyway.

Whatever you decide I hope it works out for you.

[Clarkey]

Hi Puffy, Sorry for not being very clear just frustrated and went into overdrive thinking of all the options available. I can think of 3 options to go for that are all risky with a 50/50 chance of a success or a failure.

Diagnostic arthroscopy to evaluate the whole knee fixing any damage and removal of scar tissue.

Patella decompression surgery Next option to go for that Prof Snow is happy to do but has a risk of causing even more scaring.

Osteotomy Was mentioned as a borderline case in 2015. Would it be worth comparing my left knee to my right knee. Not sure if the NHS would fund an MRI and CT scan? I might have to pay for it privately. Then Prof Snow or another OS can compare the rational angles of both knees to see if there any significant differences.

I am a novice just thinking in a common sense way to look into ways of getting to the bottom of my ongoing knee problems. Sorry if I come across irrational earlier on my previous posts, we all know with our knee problems we can at times get defensive when we don't mean to be.

Friday group meeting with OS's discuss together more complex hard to fix joint problems that the Sports Medicine Doctor said to my mum and I. One of the OS might say I will take on both Nick's knee and hip problems trying to find a way to ease the pain and discomfort. Vicky is right seeing OS that deals with hip and knee pain. No disrespect to Prof Snow who does knee and shoulder surgery. A hip & Knee OS has the knowledge and experience working with the two joints.

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